Basic Information
| Provider Information | |||||||||
| NPI: | 1043328743 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VISUAL HEALTH @ FT. LAUDERDALE, INC | ||||||||
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| OtherOrganizationName: | VISUAL HEALTH OF FT. LAUDERDALE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1097 S. LE JEUNE ROAD | ||||||||
| Address2: | SECOND FLOOR | ||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331342616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054422020 | ||||||||
| FaxNumber: | 3054427354 | ||||||||
| Practice Location | |||||||||
| Address1: | 2540 NE 9 ST | ||||||||
| Address2: | |||||||||
| City: | FT. LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333043525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054422020 | ||||||||
| FaxNumber: | 3054427354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 04/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | ARAN | ||||||||
| AuthorizedOfficialFirstName: | ALBERTO | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3054422020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 001838000 | 05 | FL | MEDICAID |